Provider Demographics
NPI:1548566276
Name:DAWSON, BRENT C (PA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:C
Last Name:DAWSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-285-4650
Mailing Address - Fax:801-285-4651
Practice Address - Street 1:3304 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-7102
Practice Address - Country:US
Practice Address - Phone:707-725-9383
Practice Address - Fax:707-725-1140
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21433363AS0400X
UT8289902-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical